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Robotic-Assisted Surgery Repairs Complex Kidney Condition In Teen

When blood was detected in the urine of 14-year-old Justin Ham of Crown Point, Indiana, his parents suspected it might be related to some congenital urologic anomalies that were corrected when Justin was a baby. A visit to a local urologist confirmed that the teenager had an ureteropelvic junction obstruction (UPJ) at the junction of the ureter and the kidney. This abnormal narrowing of the ureter, most likely formed during fetal development, was leading to hydronephrosis (dilation of the collecting system of the kidneys) and the hematuria (blood in the urine).

The urologist inserted a stent to temporarily open the ureter. A follow-up CT and MAG-3 scan revealed that Justin's UPJ was more complicated than most. The test showed that his right ureter was completely blocked and his left ureter was narrowing and partially blocked. In addition, Justin had a horseshoe kidney -- the lower pole of the kidneys was fused together. While congenital malformations involving kidneys are fairly rare, the horseshoe kidney is one of the most common kidney birth defects, occurring in one of every 500 births.

Justin Ham and Mohan Gundeti, MD Justin Ham and Mohan S. Gundeti, MD

Doctors agreed that Justin needed to undergo pyeloplasty -- surgery to remove the narrow part of the ureter and then reconnect the ureter to the kidney. Uncomfortable with the suggestion by some urologists that the horseshoe kidney be separated during the pyeloplasty, Justin's parents, Mike and Sherri Ham, looked for other options. Their search brought them to Mohan S. Gundeti, MD, associate professor of surgery, pediatrics and obstetrics/gynecology and director of pediatric urology at the University of Chicago Medicine Comer Children's Hospital. Dr Gundeti, an expert in minimally invasive urologic surgery, had recently performed the first pediatric robotic-assisted pyeloplasty in the Chicago area.

In a robotic-assisted procedure, the surgeon has a three-dimensional view of the surgical field and a greater range of motion and precision than in traditional laparoscopic and open surgeries. "Justin's anatomy was complex and required delicate work," says Dr. Gundeti. "But I did not see any reason to separate the kidney."

Justin's parents were happy with Dr. Gundeti's approach. "We were looking for a laparoscopic operation," says Michael Ham, Justin's father. "When we learned that robotic-assisted laparoscopic surgery gives greater surgical accuracy, has shorter recovery times and has fewer complications, we knew we were in the right place."

Dr. Gundeti examines Justin's scars Justin's post-surgical scars are barely visible because robotic minimally invasive surgery requires only tiny incisions.

On Tuesday, February 5, 2008, Dr. Gundeti performed the robotic-assisted, minimally invasive surgery through four tiny incisions. Seated at a console just a few feet away from Justin while viewing the image of the surgical field on a screen, Dr. Gundeti used open-surgery hand movements that were precisely replicated by four robotic arms. During the surgery, Dr. Gundeti discovered that Justin had another abnormality -- an extra renal artery and an extra vein, both located at the lower part of the kidney.

"The extra blood vessels made the surgery more challenging," says Dr. Gundeti. "While this is expected in a horseshoe kidney, the surgery requires meticulous work so kidney function isn't compromised." Assisted by Arieh Shalhav, MD, professor of urology and director of minimally invasive surgery at the University of Chicago, Dr. Gundeti repositioned the extra artery and vein along with the pyeloplasty.

Justin returned home and was back at school on Monday, February 11. A basketball player on his school's team, he was soon eager to demonstrate his high vertical jump.

"I had to stop him and remind him to take it easy for a few more weeks," says Justin's mom, Sherri Ham. "His body felt and looked so good, he didn't seem to realize what happened to him inside."

Justin's parents shared the following words of thanks with Dr. Gundeti:
"The Ham family wishes to thank you, Dr. Reynolds (a resident physician) and the hospital staff for all you did for Justin! This experience was difficult, but was made easy because of your personality, professionalism and bedside manner. In the past we had never experienced that effort by a doctor. You and Dr. Reynolds have mastered your communication skills in a way that the children and their families have a sense of ease that removes the anxieties associated with these tough life experiences. Again thank you and all of those associated with Justin’s case!

Spring 2008


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